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REVIEW ARTICLE

Pelvic Girdle Pain and Low Back


Pain in Pregnancy: A Review
Era Vermani, FRCA*; Rajnish Mittal, FRCS; Andrew Weeks, MRCOG
*Department of Anesthesiology, University Hospital Aintree; Department of Emergency
Medicine, Royal Liverpool University Hospital; Division of Perinatal and Reproductive
Medicine, Liverpool Womens Hospital, Liverpool, U.K.

Abstract: Pregnancy-related pelvic girdle pain (PGP) and


pregnancy-related low back pain (PLBP) are common problems with significant physical, psychological, and socioeconomic implications. There are several management options
that are underutilized because of lack of comprehensive
knowledge by health-care professionals and fear of harmful
effects of treatment on the developing fetus. Interventions
such as patient education, the use of pelvic belts, acupuncture, and aquatic and tailored postpartum exercises can be of
some benefit to these patients. This article will focus on the
diagnosis and management of PGP and PLBP, with discussion
of terminology, epidemiology, risk factors, pathophysiology,
and prognosis.
Key Words: pelvic girdle pain, pregnancy-related
pelvic girdle pain, pregnancy-related low back pain,
pregnancy-related lumbopelvic pain, symphysis pubis
dysfunction

INTRODUCTION
It is easy to underestimate the problem of pregnancyrelated pelvic girdle pain (PGP) and pregnancy-related
low back pain (PLBP). In reality, both conditions are
very common, with around 45% of all pregnant women
Address correspondence and reprint requests to: Era Vermani, FRCA,
8, Carolina Road, Great Sankey, Warrington WA5 8DB, U.K. E-mail:
erajnish100@hotmail.com.
Submitted: June 28, 2009; Revision accepted: August 16, 2009
DOI. 10.1111/j.1533-2500.2009.00327.x

2009 World Institute of Pain, 1530-7085/10/$15.00


Pain Practice, Volume 10, Issue 1, 2010 6071

and 25% of all postpartum women suffering from PGP


and/or PLBP.1 This pain can have an adverse impact on
the quality of life (QOL) for women who are affected,
and there is some evidence of socioeconomic detriment
mainly as a consequence of absenteeism from work.2,3
Despite these facts, it appears that health-care workers
still lack comprehensive knowledge about the available
management strategies and fear the possible harmful
effects of treatment on the developing fetus. Women are
encouraged to believe that these conditions are temporary and self-limiting (which may not always be the case),
and their complaints are dismissed as normal aches and
pains of pregnancy. Anecdotally, there appear to be an
increasing number of patients who are requesting induction of labor or even elective cesarean section before the
recommended 39th week of gestation in order to achieve
symptomatic relief. Such delivery options clearly increase
the risk to both mother and baby while also having
significant resource implications.4,5
Most of the literature does not distinguish between
PGP and PLBP. It is possible, although not easy, to
distinguish between the two types of pain based on the
site and character of the pain, its intensity, and the
resultant disability.6 A number of pain provocation tests
have also been described.
This article will focus on the diagnosis and management of PGP and PLBP, with discussion of terminology,
epidemiology, risk factors, pathophysiology, and
prognosis.

Pelvic Girdle and Low Back Pain in Pregnancy 61

LITERATURE SEARCH
The literature search was performed in Medline,
PubMed, Google, Embase, Ovid, DAREnet, Cumulative
Index to Nursing and Allied Health Literature, and
Cochrane library using the search terms listed in Table 1
for the last 30 years. From the review of abstracts, we
identified the articles useful for our review. All useful
articles in English and their relevant cross-references
were collected. The first two authors (E.V. and R.M.)
independently studied these articles, decided on their
relevance to the review, and summarized the key findings, and any discrepancies were resolved by discussion
with the third author (A.W.).

TERMINOLOGY
There are a number of terms in literature used to
describe pelvic girdle pain (Table 1). Symphysis pubis
dysfunction is the term that is familiar to many medical
professionals, but it has been generally superseded in the
literature by pelvic girdle pain because the condition is
rarely restricted to the pubic symphysis.7 Most of the
terms in the literature allude to the suspected pathophysiological mechanisms for this pain, which are still
not entirely clear. In this article, we have chosen to use
the terms coined by Wu et al., which are PGP, PLBP, and
lumbopelvic pain.1 These authors have used the word
pregnancy related to take into account the fact that
complaints can also start after delivery (the use of alternate words such as in pregnancy and after pregnancy would be unnecessarily limiting).1 The term
pelvic girdle pain rather than pelvic pain points to
pain being of musculoskeletal rather than gynecological
origin.1 Lumbopelvic pain includes PGP, PLBP, and their
Table 1. Terminology Used in Literature to Describe PGP
and PLBP
Symphysis pubis dysfunction
Pelvic girdle pain
PGP
PLBP
Lumbopelvic pain
Pelvic girdle relaxation
Pelvic insufficiency
Pelvic arthropathy
Backache during pregnancy
Peripartum pelvic pain
Symptom-giving pelvic girdle relaxation
Pregnancy-related pelvic pain
Posterior pelvic pain after pregnancy
Relaxation of pelvic joints in pregnancy
Pelvic instability
Symphysiolysis
PGP, pregnancy-related pelvic girdle pain; PLBP, pregnancy-related low back pain.

combination.1 There is an explicit need for standardization of terminology for PGP and PLBP in order to
improve perception and promote optimal management
of these conditions.
In this article, we will use the term PGP to refer to
pain in the symphysis pubis and/or pain in the regions of
one or both sacroiliac joints (SIJs) and pain in the gluteal
region, and we will use the term PLBP for pain in the
lumbar region.

EPIDEMIOLOGY
Although the vast majority of studies on PGP/PLBP has
been carried out in Scandinavia, studies have also been
carried out in The Netherlands,8 the U.S.A.,9 the U.K.,10
Australia,11 Africa,12 Iran,13 and Israel,14 indicating that
PGP and PLBP are universal problems.15
Studies report a wide range of prevalence (4% to
76%) of PGP and/or PLBP.1,6,14,16,17 This variation is a
result of the criteria employed by various studies for the
diagnosis of PGP and/or PLBP (patient self-report, doctors report, or history and clinical examination as diagnostic criteria), design of the study (prospective or
retrospective), sample size, and location of the pain in
the back.1,16
Wu et al., in their systematic review of 28 studies,
found that around 45% of all pregnant women and
25% of all postpartum women suffered from PGP
and/or PLBP.1 Of all those pregnant mothers, 25% had
severe pain and 8% had severe disability. Severe pain
also featured in 7% of all the postdelivery patients.
Overall, PGP was the most common condition, affecting
50% of the symptomatic patients. PLBP affected 33%,
while the remaining 17% had features of both the conditions.1 Vleeming et al., in their systematic review,
found a 20% point prevalence of PGP.16 Most women
with PGP recover a few weeks or months after delivery,
but 8% to 10% continue to have pain for 1 to 2
years.1820

RISK FACTORS
There are a large number of diverse factors that have
been evaluated for association with PGP and/or PLBP
(Table 2). Wu et al., in their analysis of 34 studies, identified strenuous work, previous low back pain, and a
previous history of PGP or PLBP as strong predictors for
pregnancy-related lumbopelvic pain (PGP + PLBP).1
They speculated that the above factors result in local
tissue damage, which predisposes to subsequent development of the symptoms. Similarly, Bastiaanssen et al.,
in an analysis of 25 studies, also found that the above

62 vermani et al.

Table 2. Risk Factors Evaluated in Various Studies for


PGP and PLBP
Physical Factors
Age
Weight
Height
Body mass index
Parity
Oral contraceptives
Smoking
Social conditions
Psychosocial Factors
Stress level
Work satisfaction
Strenuous work
During Pregnancy/Labor
Higher fetal weight
Prolonged second stage of labor
Traumatic delivery
Excessive hip abduction
Others
Previous low back pain
Previous history of PGP or PLBP
Low back pain during menstruation
Trauma to the back
PGP, pregnancy-related pelvic girdle pain; PLBP, pregnancy-related low back pain.

three factors were associated with the development of


PGP.15 Vleeming et al., in their systematic review, identified history of previous low back pain and previous
trauma to the pelvis as risk factors for developing PGP.16
Factors that do not affect the risk include use of
contraceptive pills, time interval since last pregnancy,
height, weight, smoking, and age.16 Furthermore,
epidural/spinal anesthetic and analgesic techniques are
not associated with the development of this pain.21

PATHOPHYSIOLOGY OF PGP
The underlying mechanisms that lead to the development of PGP remain speculative, although mechanical,22,23 traumatic,24 hormonal,11 metabolic,25 and
degenerative26 factors have all been proposed.
The pathophysiology is based on conjecture, and the
most plausible hypothesis behind the development of
PGP is a combination of both hormonal and biomechanical factors.27 The pelvis is a platform that serves to
transmit load from the trunk to the legs. For the load to
be effectively transferred and for the shear forces to be
minimized across the joints, the pelvis needs to be optimally stabilized. This stabilization, which is primarily
needed at the SIJs, is achieved by specific anatomic
characteristics (so called form closure). These include
the ridges and grooves in the articular surfaces of the
SIJs. The wedge shape of the sacrum allows it to fit
tightly between the ilia, while there are additional com-

pression forces (so called force closure), which are


generated by the muscles, fascia, and ligaments, that
attach to the pelvis and act across the SIJs to give the
joints their stability.28,29
Relaxin is a polypeptide hormone that is produced in
increased quantities by both the corpus luteum and the
uterine decidua during pregnancy.11 By relaxing the connective tissue, it leads to greater ligamental laxity,
particularly in the joints of the pelvis. This results in
the widening and separation of the symphysis pubis,
which can be demonstrated radiologically in pregnant
women.22,30 There is also evidence that there is both
increased SIJ laxity and greater synovial fluid volume in
pregnant women, although these findings come from
postmortem studies.23 A recent systematic review found
that patients with PGP have increased motion in their
pelvic joints as compared with healthy pregnant controls.31 This increased motion in the pelvic joints, in
pregnant women with PGP, diminishes the efficiency of
load transmission and increases the shear forces across
the joints.25 These increased shear forces might be
responsible for pain in pregnant women with PGP.25

CLINICAL FEATURES
PGP and PLBP usually start around the 18th week of
pregnancy (peak intensity between 24th and 36th
weeks), but can also start in the first trimester or be
delayed as late as 3 weeks after delivery.1,32
PLBP
PLBP is characterized by lumbar region pain. It is dull in
character and is experienced when the patient is in
forward flexion. There is restriction of spine movement
in the lumbar region, and palpation of the erector spinae
muscles exacerbates pain.6 The pain resembles the back
pain that occurs in the nonpregnant state.33
PGP
Vleeming et al. have defined PGP as: In PGP pain is
experienced in-between the posterior iliac crest and the
gluteal fold, particularly in the vicinity of the sacroiliac
joints (SIJ). The pain may radiate into the posterior
thigh and can also occur in conjunction with/or separately in the symphysis pubis.16 The pain has been
described as stabbing, shooting, dull, or burning.34,35
The average visual analog score for pain is 50 mm to
60 mm on a 100-mm scale.6,17 The pain is intermittent
and can be precipitated by prolonged sustained postures
and simple activities of daily living such as walking,
sitting, or standing (generally starting within 30 minutes

Pelvic Girdle and Low Back Pain in Pregnancy 63

of an activity).35 Some patients describe an occasional


catching sensation in the leg while walking.36 There is
no restriction of movements of the lumbar spine or of
the hip joint. Twisting, climbing stairs, unequal weight
bearing on legs, and turning in bed can aggravate the
symptoms. It is characterized by positive pelvic pain
provocation tests.
PGP can become more severe with subsequent pregnancies.37,38 PGP tends to be more severe than PLBP
during pregnancy, while the reverse situation has been
observed during postpartum period.39 PGP has been
classified into 5 classes according to the site of pain.
These are (1) anterior in the symphysis pubis, (2) posterior in either right or left SIJ, (3) both SIJs, (4) miscellaneous, and (5) complete pelvic girdle syndrome with
pain in all three pelvic joints.40 Patients with pain only in
the symphysis pubis appear to have the best prognosis,
while those with complete pelvic girdle syndrome have
the worst long-term outcome.19
Disability in Women with PGP/PLBP
Women with PGP and PLBP find difficulty with normal
activities, such as getting up from a sitting position,
turning over in bed, prolonged sitting, prolonged
walking, dressing and undressing, and lifting and carrying small weights.33,41 Women with combined lumbar
and posterior pelvic pain are more disabled, and some
may be incapacitated to the extent of using crutches and
wheelchairs.41,42 Women with complete pelvic girdle
pain are more likely to use crutches.41 Sexual difficulties
are common. Hansen et al., in their descriptive
questionnaire-based study on 227 women with pelvic
pain, found that 82% of women had problems during
sexual intercourse, and 20% of these women could not
participate in sexual intercourse at all, because of disabling pain.34 Similarly, Mogren, in his questionnairebased survey on 1,071 immediate postpartum women,
found that pregnant women with back pain-related pain
scores of 7/10 or more at any time during pregnancy
were more likely to have an unsatisfying sexual life
during pregnancy as compared with women without
such pain.43 The patients with PGP are more disabled as
they have much higher pain scores and are more difficult
to treat than patients with PLBP.6,32
Our search revealed only one study in which QOL of
pregnant women with back pain was assessed using a
QOL index.44 This study, which included 160 women in
late pregnancy, found that women with back pain had
greater reduction in QOL indices as compared with
pregnant women without back pain.44

MAKING THE DIAGNOSIS


Excluding Serious Pathology
For women presenting with low back pain and/or pelvic
pain in pregnancy, a thorough history and physical
examination should be carried out. The aim is to
exclude other causes of pain (Table 3), to differentiate
between PGP and PLBP, to assess disability, and to formulate an individualized management plan. Warning
signs such as history of trauma, unexplained weight
loss, history of cancer, steroid use, drug abuse, human
immunodeficiency virus infection or immunosuppressed
state, neurological symptoms/signs, fever, or systemically unwell should be sought as they point toward
other serious causes of pain. These red flags point
toward the presence of underlying conditions that might
be inflammatory, infective, traumatic, neoplastic, degenerative, or metabolic.45 Moreover, pain that does not
improve with rest and severe disabling pain warrant a
meticulous examination, diagnostic investigations, and
specialist referral. Focal inflammatory signs and tenderness of the spine may suggest osteomyelitis, and a step
felt on examination of spine may suggest spondylolisthesis (where there is slippage of one vertebral body
on the adjacent one). The presence of neurological signs
such as bowel, bladder, sensory, motor, or reflex involvement may suggest cauda equina syndrome, lumbar disk
lesion, spinal stenosis, or any other compressive lesion
around the spinal cord, and require urgent specialist
referral. Symptomatic lumbar disk herniation, although
uncommon in pregnancy, should always be excluded,
although it has been found that magnetic resonance
imaging (MRI) finding of lumbar disk herniation
in pregnant patients with or without back pain has
the same prevalence as in nonpregnant asymptomatic
patients.46,47
Table 3. Differential Diagnosis of PGP and PLBP
Urinary tract infection
Osteomyelitis
Lumbar disk lesion/prolapse
Arthritis of spine/hip
Lumbar stenosis
Cauda equina syndrome
Spondylolisthesis
Pregnancy-associated osteoporosis
Femoral vein thrombosis
Osteitis pubis
Rupture of symphysis pubis
Sciatica
Obstetric complications (preterm labor, abruption, red degeneration of
uterine fibroid, round ligament pain, and chorioamnionitis)
PGP, pregnancy-related pelvic girdle pain; PLBP, pregnancy-related low back pain.

64 vermani et al.

Differentiating between PGP and PLBP


It has been suggested that it is important to distinguish
between the two conditions, as the management and
prognosis of the two conditions may differ.6,15 Useful
methods of differentiation include the site of pain, its
character and severity, provoking factors, resultant disability, and the pain provocation tests.6 Pain referral
maps can also be helpful in differentiating between PGP
and PLBP. In a typical drawing of PGP, the pain is
concentrated under the posterior superior iliac spine, in
the gluteal area, the posterior thigh, and the groin.27 In
contrast, patients with PLBP show the pain to be concentrated in the lumbar region above the sacrum.27
Pain Provocation Tests
A number of pain provocation tests have been described
for the diagnosis of PGP. Majority of these tests have
high specificity but low sensitivity,16 indicating that if a
test is negative, then the patient is unlikely to have PGP.
It is recommended to perform as many tests as possible,
taking into account the low sensitivity of the tests.16 The
posterior pelvic pain provocation test, Patricks test, and
the long dorsal sacroiliac ligament test are recommended for the diagnosis of the pain in the region of
SIJs.27 For pubic symphysis pain, direct palpation of the
symphysis pubis, modified Trendelenbergs test, and
active straight leg raising tests are recommended.27
The Posterior Pelvic Pain Provocation Test. The
patient lies supine and the hip is flexed to 90. The
examiner applies pressure on the flexed knee in
the longitudinal axis of the femur while stabilizing the
pelvis, with the other hand resting on the opposite anterior superior iliac spine. The test is considered positive if
this maneuver produces deep pain in the gluteal
region.48
Patricks or FABER (Flexion, ABduction, External
Rotation Test). With the patient lying supine, the
examiner flexes the hip, and abducts and externally
rotates one leg to bring the ipsilateral heel to rest on the
opposite knee. The patient is asked to relax the limb to
allow the weight of the leg to draw the knee toward the
floor. The test is considered positive if pain is felt in the
ipsilateral SIJ or in the symphysis pubis.49

patient in a supine position with both legs straight and


with feet 20-cm apart. The woman is asked to raise one
leg after the other to a height of 20 cm above the examination table without bending the knee. The degree of
difficulty in performing this is a quick indicator of the
severity of the overall condition and correlates well with
more detailed back pain disability scores.50
Long Dorsal Sacroiliac Ligament Test. The patient
lies on her side with slight flexion in both hip and knee
joints, and is tested for tenderness on bilateral palpation
of the long dorsal sacroiliac ligament, directly under the
caudal part of the posterior superior iliac spine. The
degree of tenderness is related to the severity of the
condition.51
Pain Provocation of the Symphysis Pubis by Modified
Trendelenburgs Test. The patient stands on one leg
and flexes both the hip and the knee of the other leg to
90. If the woman experiences symphyseal pain, then
the test is considered positive.49
The posterior pelvic pain provocation test and
Patricks or FABER test are carried out in supine position. As eliciting these tests can be very painful for the
affected women, these tests should be carried out
bearing this in mind and the supine position kept for the
briefest possible duration in pregnant women to minimize the effects of supine hypotension syndrome on the
mother and the baby.
Imaging
The diagnosis of PGP and PLBP is largely clinical. Ultrasound has been used to measure the interpubic gap
between the two pubic bones at the symphysis pubis,
but there is no correlation between the severity of symptoms and the degree of separation.52 X-ray imaging
techniques such as computed tomography scans are
not ideal in pregnancy, but MRI is thought to be safe,53
although long-term follow-up studies are awaited.
Therefore, currently, the use of MRI should be reserved
for the investigation of back pain in pregnancy where
there is a strong suspicion of abnormality such as the
presence of neurological signs.

MANAGEMENT
Prevention

Active Straight Leg Raise Test. This test has been


shown to be useful for the assessment/diagnosis of PGP
in postpartum women. The test is performed with the

A number of studies have shown that physical fitness


exercises before pregnancy reduce the risk of developing
back pain in any subsequent pregnancy.6,54 This benefi-

Pelvic Girdle and Low Back Pain in Pregnancy 65

cial effect of exercise is similar to that seen in the general


population.55 Also, Mantle et al., in a controlled study on
208 primiparous women, found that back care advice
given to pregnant women in early pregnancy was useful
in diminishing the severity of back pain during the course
of their pregnancy.56 In contrast, a prospective randomized study of 362 healthy pregnant women by Ostgaard
et al. found that antenatal patient education and exercises in asymptomatic healthy women had no effect on
the development, or on the regression, of back pain
during subsequent pregnancies. The only subgroup that
benefited from such interventions was pregnant women
with a previous history of back pain.57 Therefore, the use
of antenatal back care education in healthy women does
not appear to be of any great benefit.
Treatment Options
Patient Education. Individualized education and training programs have been found to be effective in reducing
absenteeism from work in women with back pain, but
not in women with PGP.6 Back care classes focus on
educating women in the relevant anatomy, ergonomics,
correct posture, pain management strategies, and relaxation techniques. Pregnant women with back pain should
avoid fatigue, twisting while lifting, and unrelenting
postures; maintain good upright posture; and take frequent periods of rest.7 In addition, women with PGP
should avoid activities such as jarring, bouncing, unequal
weight bearing on legs (eg, while dressing), hip abduction, and activities that strain the joints to their
extreme.31 While turning in bed, knees should be flexed
and squeezed together.33 Although there are no studies in
the literature that have evaluated patient information as
a single intervention, providing adequate information
and reassurance is considered useful.16
Physical Therapy. The use of devices as simple as a
pillow in the shape of a nest has been found to be useful
in decreasing pain and insomnia during late pregnancy.58 The pillow supports the abdomen when the
woman is in the lateral recumbent position and appears
to relieve symptoms. Other devices that can be used
include a lumbar roll placed behind the lower back
(while resting with feet slightly elevated), abdominolumbar supports,59 and sacroiliac belts.6 Women should
be encouraged to experiment with cushions and pillows
of various sizes and shapes to support different parts
of their body, such as their back, abdomen, and knees
for pain relief.33 Pelvic belts decrease the mobility of the
SIJs and work most effectively when they are applied

just below the anterior superior iliac spines rather than


at the level of the symphysis pubis.60 There is no good
quality evidence to support the use of nonelastic pelvic
belts. Some women are apprehensive that the pressure
from various abdomino-lumbar supports will have
deleterious effects on the fetus, but such fears are
unfounded, and the use of an abdomino-lumbar support
is safe.61 A pelvic belt may be fitted to test for symptomatic relief, but it should only be applied for short
periods.16 Other interventions include massage and
local application of heat and cold. Field et al., in their
quasi-randomized controlled trial carried out on a
small group of 26 patients, found some benefit of
massage in pregnant women with back pain.62 Stuge
et al., in their review of 1,350 patients, found no
strong evidence regarding the effect of various physical
therapy interventions for the prevention and treatment
of PGP and PLBP.63 This should not dissuade clinicians
from using these simple harmless measures on their
patients. There is no good quality evidence to support
the use of pelvic manipulation, mobilization, or sacroiliac fusion, therefore, such extreme interventions
cannot be recommended.27 Other useful aids include
elbow crutches, walking frames, and wheelchairs to
assist mobility.
Exercises. Exercises appear to be beneficial mainly in
patients with PLBP,6,64,65 but their role in diminishing
PGP during pregnancy remains uncertain. Our search
revealed only one randomized controlled trial of high
methodological quality in which specific diagnostic criteria for PGP were used. In this study on 118 pregnant
women with PGP, it was found that pelvic stabilizing
exercises neither decreased the pain intensity nor shortened the recovery period after delivery.66 This could be
related to the fact that the transverse abdominal muscles
cannot be trained during pregnancy. The exercises recommended for PLBP are similar to those used in nonpregnant backache patients, with minor modifications
for pregnancy.67 Once the acute pain is settled, individually tailored back strengthening and stretching exercises
can be started. Ostgaard et al. found that an individualized training program based on information, ergonomic advice, and exercises resulted in reduction of sick
leave in pregnant women with back pain, but not in
those with PGP.6 Water gymnastics have also been found
to be useful in diminishing back pain and sick leave in
pregnant women.68
Exercise may however offer some benefit to women
with PGP following delivery. Stuge et al., in a random-

66 vermani et al.

Table 4. Controlled Trials of Acupuncture


First Author
(Country)
Wedenberg
et al.74 (Sweden)
Guerreiro da
Silva75 (Brazil)
Kvorning et al.76
(Sweden)
Elden et al.77
(Sweden)
Lund et al.78
(Sweden)

Year

Patient Numbers
Active + Control

Intervention in
Control Group

2000

30 + 30

2004

27 + 34

Physiotherapy: only 40% drop


out from controls
Standard Rx

2004

37 + 35

Not known

2005

130* + 125 + 131

2006

25 + 22

Standard Rx (information,
pelvic belt) 1 exercises
Superficial acupuncture

Outcome
VAS decreased by 60% in the acupuncture group vs.
31% in the physiotherapy group
NRS decreased by 50% in 78% of acupuncture group
patients vs. 50% decrease in 15% of the controls
VAS decreased in 60% of the acupuncture group vs.
14% of controls (P < 0.01)
VAS decreased by 52% in acupuncture + standard Rx
group vs. 8% in only standard Rx group vs. 26% in
standard treatment + stabilizing exercises group
No difference, ie, equal VAS decrease

* Standard treatment.
Standard treatment + acupuncture.

Standard treatment + stabilizing exercises.


NRS, numeric rating scale; Rx, treatment; VAS, visual analog scale.

ized controlled trial on 81 postpartum patients with


PGP, found specific pelvic girdle stabilizing exercises to
be useful.69 In contrast, Mens et al., in a randomized
controlled trial on 44 patients with PGP, found no
change in pain intensity and no difference in mobility of
pelvic joints in women who performed diagonal trunk
muscle exercises as compared with the control group.70
In the latter study, the small sample size, poor supervision, and poor compliance with exercises probably
influenced the results.66
Transcutaneous Electrical Nerve Stimulation. There
are no randomized controlled trials of transcutaneous
electrical nerve stimulation (TENS) in pregnancy except
for in labor. There have been theoretical concerns about
stimulation of certain acupuncture points (which have
been used to induce labor), fetal malformations, and
passage of current through fetal heart while using
TENS. However, no negative effects have been reported
from the use of TENS during any stage of pregnancy.71
TENS can be used in pregnancy provided the usual
precautions and contraindications are observed, the
current density is kept low, and the acupuncture points
used to induce labor are avoided.71 According to a
recent Cochrane review, there was limited and inconsistent evidence to support the use of TENS as an isolated
intervention even in the management of chronic low
back pain.72 However, there is some evidence that TENS
is better than giving no treatment in chronic low back
pain (although this could have been a placebo effect).73
Given the limited options available for pain relief during
pregnancy, there appears to be no disadvantage in trying
TENS. It is cost-effective, readily available, poses less
risk than analgesic medications, and is less labor-

intensive than acupuncture. It should be used as a


second-line treatment for PLBP/PGP, after advice on
daily activities and exercises.71
Acupuncture. The use of acupuncture for PGP/PLBP is
increasing.7481 Most studies are controlled trials of
series of small numbers of patients, and they suffer
potential bias from their lack of blinding of both the
patient and the investigator (Table 4). The acupuncturist must avoid certain acupuncture points in pregnancy
that supply the cervix and uterus (which have been used
to induce labor), but the technique in general is considered to be safe. The majority of the older studies has
found that acupuncture provides effective analgesia to
women with PGP and/or PLBP in pregnancy.7477,79 A
recent randomized double-blinded controlled trial in
115 patients diagnosed with PGP has shown that acupuncture had no significant effect on pain or on the
degree of sick leave compared with nonpenetrating
sham acupuncture, although there was some improvement in performing daily activities.82 However, acupuncture has been widely shown to be of benefit in the
management of chronic lower back pain.83,84 Given its
effectiveness for these conditions and the limited treatment options available during pregnancy, further high
quality trials are needed to evaluate its use for PGP/
PLBP. However, it is labor-intensive, with courses of
treatment usually requiring at least 6 sessions with a
trained practitioner.
Pharmacotherapy. There are no studies on the use of
drugs in PGP/PLBP in pregnancy. Although paracetamol
is considered safe in pregnancy, it does not seem to be
very effective on its own for these conditions. The use of

Pelvic Girdle and Low Back Pain in Pregnancy 67

nonsteroidal anti-inflammatory drugs (NSAIDs) is not


associated with fetal malformations before 30 weeks of
pregnancy.85 However, the majority of women is
unlikely to require treatment for PGP/PLBP in early
pregnancy. NSAIDs are generally withheld in the last
trimester of pregnancy because of the risk of premature
closure of the ductus arteriosus and the risk of oligohydramnios.85 A prospective observational study on 88
pregnant patients with rheumatic arthritis did not
however reveal any immediate or long-term effects on
the infants of the 45 women who were treated with a
standard dose of NSAIDs for a mean duration of 15.3
weeks (the drugs were stopped 4 to 6 weeks before
delivery).86 NSAIDs can be used safely after delivery in
breast-feeding mothers.
Opioids such as morphine, codeine, meperidine,
tramadol, hydrocodone, fentanyl, propoxyphene,
and oxymorphone are included in category C of the
pregnancy risk category by the Food and Drug
Administration.8789 Category C includes drugs that
have been shown to pose fetal risk in animal studies,
where there are no well-controlled human studies and the
benefits from the use of the drug in pregnant women may
be acceptable despite its potential risks.90 Morphine,
meperidine, codeine, and propoxyphene in early human
pregnancy have not been found to be associated with any
increased risk of fetal malformations.91 The use of
opioids in late pregnancy and in breast-feeding mothers
can result in respiratory depression in the neonate, and
withdrawal effects in newborns of mothers on long-term
opioids.92 There is little evidence upon which to base
the use of opioids to alleviate the pain of PGP/PLBP,
but small doses, especially at night, may help to provide
nocturnal pain relief and a better quality of sleep.
Epidural Analgesia. There is a potential role for epidural analgesia in the management of severe PGP/PLBP,
but it has not been properly evaluated and the evidence,
as it is, is restricted to a few isolated case reports.93,94 In
the first case, single-shot epidural morphine was given,
and in the second intermittent, epidural top ups of bupivacaine and fentanyl were given through an indwelling
epidural catheter (for 72 hours) with good results.93,94 If
epidural is to be used for analgesia in PGP/PLBP, then
there is a likelihood of needing an epidural infusion
through a long-term indwelling epidural catheter. This
can be associated with tachyphylaxis and risks such as
motor block (can interfere with the patients mobility),
hemodynamic instability, respiratory depression, pruritis, and urinary retention, with possible consequences

for both the mother and the baby. This extreme


approach might have a place in patients with severe PGP
for symptom control while awaiting fetal maturation,
thereby avoiding premature induction/cesarean section.

MANAGEMENT OF LABOR
Our search did not reveal any studies on the management of labor in women with PGP/PLBP. The Association of Chartered Physiotherapists in Womens Health
has produced guidelines for the management of labor in
women with PGP.7 It recommends avoiding undue
abduction of hips during labor in the affected women
(especially under the pain-masking effect of spinal/
epidural anesthesia) to prevent further damage to the
pelvic girdle joints. It further recommends promoting
the most comfortable position for the mothers during
labor, vaginal examination, operative vaginal delivery,
and suturing. This is likely to be a lateral position or on
all fours. If lithotomy position is needed, it should be
maintained for as short a duration as possible, and care
should be taken to ensure simultaneous movement of
legs into, and out of, this position. For assisted vaginal
delivery, ventouse is preferable. Cesarean section does
not confer any benefit on outcome but may be the only
option in women in whom there is severe pain and
limitation of movement, making comfortable birthing
position practically impossible. Following birth, it
suggests that women start on analgesics or antiinflammatory medications. Once the pain is controlled,
and after a period of bed rest, women should gradually
mobilize within pain limitation, using aids such as pelvic
supports/elbow crutches.7

PROGNOSIS
PGP is usually a self-limiting condition, and symptoms
generally resolve within a few weeks to a few months
after delivery. Risk factors associated with long-term
PGP include prepregnancy back pain, prolonged duration of labor,20 a high number of positive pain provocation tests, a low mobility index,19 the onset of severe
pain at early gestation, and inability to lose weight
following delivery to the prepregnancy level.95 Women
with complete PGP (pain in symphysis pubis and both
SIJs) have the worst long-term prognosis.19 About 8% to
10% of the women with PGP continue to have pain for
1 to 2 years.1820 Although PGP/PLBP tends to recur in
future pregnancies, there are no studies in literature that
have shown PGP/PLBP to be associated with future back
pain without pregnancy.

68 vermani et al.

RECOMMENDATIONS FOR FURTHER RESEARCH


There are widespread misconceptions about PGP/PLBP;
studies are needed to explore whether health promotion
programs can prevent these, and cost-benefit implications of these programs need to be analyzed. Good
quality studies on different forms of interventions,
including their risk-benefit and cost-benefit analysis,
should be carried out. Studies should be carried out on
the association of psychosocial factors and the role of
cognitivebehavioral treatment in PGP/PLBP.

CONCLUSION
PGP and PLBP are common problems, but they are
often underestimated and undertreated. A large number
of terms for these conditions have been used in the
literature, and there is a need for a uniform terminology
in order to promote research and management of these
conditions. Major risk factors for PGP and PLBP
include strenuous work, previous low back pain, previous history of PGP or PLBP, and previous trauma to the
pelvis. The diagnosis of PGP is clinical, based on the
pain characteristics, functional impairment, positive
pain provocation tests, and exclusion of lumbar causes
of pain. Care should be taken not to exceed the pain-free
range of abduction of hips in affected women, especially
during labor. Individualized treatment in the form of
patient education, exercises, pelvic belts, analgesics, and
acupuncture can be of benefit. Further research is
needed into the use of different forms of treatment such
as acupuncture, TENS, and epidural analgesia, either in
isolation or as complementary interventions for the safe
and effective management of these conditions.

ACKNOWLEDGEMENTS
We are thankful to Professor Turo Nurmikko and Dr.
Simon Bricker for revising and reviewing the article, and
giving their useful comments. We are also grateful to Dr.
Simon Fenner for his constant guidance and support
while writing and reviewing this article.

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